How Are Washington State s Hospitals Affected by the Nursing Shortage? Results of a 2001 Survey

Transcription

1 May 2002 Working Paper #68 How Are Washington State s Hospitals Affected by the Nursing Shortage? Results of a 2001 Survey by Susan M. Skillman, M.S. Troy Hutson, R.N., J.D. C. Holly A. Andrilla, M.S. Bobbie Berkowitz, R.N., Ph.D. L. Gary Hart, Ph.D. University of Washington School of Medicine Department of Family Medicine

2 ABOUT THE WORKFORCE CENTER The WWAMI Center for Health Workforce Studies at the University of Washington Department of Family Medicine is one of five regional centers funded by the National Center for Health Workforce Information and Analysis (NCHWIA) of the federal Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA). Major goals are to conduct highquality health workforce research in collaboration with the BHPr and state agencies in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI); to provide methodological expertise to local, state, regional, and national policy makers; to build an accessible knowledge base on workforce methodology, issues, and findings; and to widely disseminate project results in easily understood and practical form to facilitate appropriate state and federal workforce policies. The Center brings together researchers from medicine, nursing, dentistry, public health, the allied health professions, pharmacy, and social work to perform applied research on the distribution, supply, and requirements of health care providers, with emphasis on state workforce issues in underserved rural and urban areas of the WWAMI region. Workforce issues related to provider and patient diversity, provider clinical care and competence, and the cost and effectiveness of practice in the rapidly changing managed care environment are emphasized. The WWAMI Rural Health and Health Workforce Research Center Working Paper Series is a means of distributing prepublication articles and other working papers to colleagues in the field. Your comments on these papers are welcome and should be addressed directly to the authors. Questions about the WWAMI Center for Health Workforce Studies should be addressed to: L. Gary Hart, PhD, Director and Principal Investigator Susan Skillman, MS, Deputy Director Roger Rosenblatt, MD, MPH, Co-Investigator Laura-Mae Baldwin, MD, MPH, Co-Investigator Denise Lishner, MSW, Center Research Coordinator Eric Larson, PhD, Senior Researcher Heather Deacon, Program Coordinator University of Washington Department of Family Medicine Box Seattle, WA Phone: (206) , ext. 3 Fax: (206) hdeacon@fammed.washington.edu Web Site: The WWAMI Center for Health Workforce Studies is supported by the Bureau of Health Professions National Center for Health Workforce Information and Analysis. Grant Nos. 1U76-MB and 6U79HP ABOUT THE AUTHORS Susan M. Skillman, MS, is the Deputy Director of the WWAMI Center for Health Workforce Studies, Department of Family Medicine, University of Washington School of Medicine. Troy Hutson, RN, JD, is the Director of Legal and Clinical Policy at the Washington State Hospital Association. C. Holly A. Andrilla, MS, is a biostatistician for the WWAMI Center for Health Workforce Studies, Department of Family Medicine, University of Washington School of Medicine. Bobbie Berkowitz, RN, PhD, is Professor and Chair of the Department of Psychosocial and Community Health, University of Washington School of Nursing. L. Gary Hart, PhD, is Director of the WWAMI Center for Health Workforce Studies and Professor in the Department of Family Medicine, University of Washington School of Medicine.

3 How Are Washington State s Hospitals Affected by the Nursing Shortage? Results of a 2001 Survey Susan M. Skillman, M.S. Troy Hutson, R.N., J.D. C. Holly A. Andrilla, M.S. Bobbie Berkowitz, R.N., Ph.D. L. Gary Hart, Ph.D. May 2002 This study was performed by the WWAMI Center for Health Workforce Studies (CHWS) and the Washington State Hospital Association (WSHA). The WWAMI CHWS is supported by the National Center for Health Workforce Information and Analysis (NCHWIA), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA). Data collection was supported by funds from the WSHA, and survey methods development and data analysis were supported by NCHWIA. Susan Yee, graduate research assistant, provided valuable data-collection assistance. mar NSFW:z:m:s 6/11/02

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5 - 3 - Table of Contents Abstract... 5 Background... 7 Methods... 9 Results Discussion References Appendix: Questionnaire... 39

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7 - 5 - Abstract Background: The registered nurse (RN) workforce in the U.S. and the national population are both aging. Nursing shortages now are being reported around the country, and are expected to increase as the demand for medical care rises with the aging of the population. The Center for Health Workforce Studies at the University of Washington and the Washington State Hospital Association teamed up to ask how acute care hospitals in the state are affected by the nurse shortage. Methods: An eight-page questionnaire was mailed to the 83 acute care hospitals in Washington. After in-person and telephone follow-up to encourage response, 68 hospitals (82%) responded. Rural-Urban Commuting Area (RUCA) codes were used to distinguish rural from urban sites. Results: Sixty-nine percent of Washington s RN hospital staff nurses are age 40 or older, and 8.4 percent are male. The hospitals employ many part-time nurses; 100 staff nurses are required to produce 70.5 full-time equivalents (FTEs). An estimated 1,987 hospital staff nurses are needed to fill the 1,401 vacant FTEs. Hospital RN vacancy rates are 9.2 percent of budgeted FTEs, with rural sites reporting slightly lower vacancy rates (8.9%) than urban sites (9.6%). Annual nurse turnover rates are 16.6 percent in both rural and urban hospitals. However, 54 percent of urban hospitals compared to 14 percent of rural hospitals said RN turnover was higher than last year. Urban hospitals find it easier to recruit newly trained RNs than do rural hospitals, but all hospitals reported that it is difficult to hire experienced nurses. The nurse specialties most difficult to recruit, in order of difficulty, were ICU/CCU, anesthesia, emergency, OR/recovery, and labor and delivery. Sixty-six percent of urban hospitals and 46 percent of rural hospitals reported they went on divert status last year because of a shortage of nurses. The hospitals used many different methods to recruit and retain nurses, but none were generally considered effective. Overall, most hospital respondents indicated that the main reason for nurse vacancies was a lack of qualified applicants and very few said they felt pay or benefits issues were the cause of the vacancies. Discussion: Washington s hospitals face the challenge of a nursing shortage similar to that of the rest of the country. The problem appears to have escalated more rapidly in urban areas than rural ones, but nurse vacancy rates and turnover are now very similar in both rural and urban hospitals. Among the short-term effects of the shortage are closing of hospital beds and diverting more

8 - 6 - of management s resources to nurse recruitment. Long-term effects are likely to be greater stress on the work environment, which contributes to nurse dissatisfaction and retention problems and impedes appropriate patient care. Solutions include increasing the supply of nurses and encouraging them to remain in the workforce longer.

9 - 7 - Background The registered nurse (RN) workforce in the U.S. is aging (see Figure 1). The average nurse is 45 years old, and more than two-thirds of the nation s nurses are over age 40 (U.S. HRSA, 2001). The main reason the nurse workforce is aging is because fewer young women are entering the profession (Buerhaus, Staiger, & Auerbach, 2000) FIGURE 1 Age of the Registered Nurse Population: Source: U.S. Health Resources and Services Administration, The Registered Nurse Population: National Sample Survey of Registered Nurses, March 2000.

10 - 8 - At the same time, the U.S. population is aging. As shown in Figure 2, it is estimated that by 2035 the number of Americans over age 65 will double (Urban Institute, 2001). An increase in absolute and proportionate numbers of older people in the U.S. population will cause increased need for health care services, including hospital services, to care for this population. FIGURE 2 Millions of Older Adults in the U.S., by Age Note: The projections of the number of people in the general population age 65 and older assume reductions in mortality of 0.6% a year. Source: Urban Institute, Based on The Long-Term Care Financing Model. Prepared by The Lewin Group, Inc., for the Office of the Assistant Secretary for Planning and Evaluation, DHHS, Nursing shortages now are being reported around the country and are expected to increase as the demand for medical care rises with the aging of the population (Center for Health Workforce Studies, 2001; First Consulting Group for the American Hospital Association, 2002; Furino, Gott, & Miller, 2000; North Carolina Center for Nursing, 2001; Sechrist, Lewis, & Rutledge, 1999). Much of the nurse shortage is being experienced by hospitals, where nearly 60 percent of RNs are employed (U.S. HRSA, 2001). Little information has been reported on whether rural and urban hospitals are affected similarly.

11 - 9 - The Center for Health Workforce Studies (CHWS) at the University of Washington and the Washington State Hospital Association (WSHA) were interested in examining the extent to which the nursing shortage was affecting acute care hospitals in Washington State. Methods To better understand and describe the effects of the nursing shortage on Washington State hospitals, in early 2001 the University of Washington s CHWS and the WSHA designed and carried out a survey of the state s acute care hospitals. The survey collected information on the nurse workforce and details of vacancies in other non-physician professions from all 83 non-federal acute care hospitals in Washington State. The survey was conducted from March through June 2001, and the data were analyzed by the CHWS. The survey design and analysis were supported with CHWS core funding from HRSA s National Center for Health Workforce Information and Analysis, and the data collection was supported by a grant from the WSHA. Questionnaire An eight-page questionnaire was developed and revised based on reviews of experts and a limited pretest. The questionnaire asked for descriptive information about the acute care hospital, employment statistics and demographics of RN employees, nurse turnover statistics, information about the hospital s level of difficulty recruiting and retaining nurses, information about the hospital s strategies to recruit and retain nurses, and a set of questions about employment, recruitment and retention of other non-physician clinical employees. A copy of the questionnaire is included as Appendix A. Data Collection The questionnaires, with cover letters, were mailed to human resource executives at each hospital, and copies of the cover letters were sent to Chief Executive Officers (CEOs) and Nursing Executives at each hospital. The CEOs and Nursing Executives were sent letters in order to encourage the hospital to respond, and to draw attention to the likelihood that the human resources executive would need input from nursing and other administrative staff in order to complete the questionnaire. As necessary, in-person (through regular WHSA

12 meetings) and telephone follow-up contacts were made with non-responding hospitals to encourage their response. The initial mailing of the questionnaire was followed by two additional mailings to non-respondents at approximately four-week intervals. Individual hospitals were sent additional copies of the questionnaire if they indicated need during phone follow-up. Rural vs. Urban Classification Many of the analyses distinguish responses of urban hospitals from those of rural hospitals. The hospitals were classified as rural or urban based on the Rural-Urban Commuting Area (RUCA) classification system (Morrill, Cromartie, & Hart, 1999). Of the 83 hospitals surveyed, 44 had ZIP codes in rural areas (RUCA categories 4.0, 5.0, 6.0, 7.0, , 8.0, , 9.0, 9.1, 9.2, 10.0, and ) and 39 had ZIP codes in urban areas (RUCA categories 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1 and 10.1). The RUCAs are a subcounty alternative to the more commonly used but less specific county-based schemes (e.g., OMB s Metro Areas). RUCAs are based on the sizes of cities and towns and functional relationships as measured by work commuting patterns. The distribution of rural and urban acute care hospitals in Washington State is shown in Figure 3. FIGURE 3 Urban and Rural Acute Care Hospitals in Washington

13 Nurse Definitions The questionnaire asked respondents to provide data on four categories of RNs employed by their hospital: staff nurses, administrator/supervisor/manager nurses, clinical nurse specialists, and advanced registered nurse practitioners. The majority of nurses employed by the hospitals are staff nurses. This category also received by far the most complete responses. For this reason, most of the analyses reported here are for staff nurse positions at the hospitals, not managerial, specialist, or advanced practice nurses. Other specific questions asked about use of temporary, registry, and travel nurses. Imputing Values for Non-Respondents To estimate the total number of staff nurses employed and the number of vacancies in the state, it was necessary to impute values for non-responding hospitals. All hospitals in the sample (respondents and non-respondents) were grouped into one of four hospital size categories based on the number of licensed acute care beds operated by the facility: smallest (fewer than 50 beds), small (50-99 beds), medium ( beds) and large (more than 250 beds). The values for non-respondents were imputed by applying the mean value obtained from responding hospitals in each size category to each of the non-respondent hospitals. Bed size for non-responding hospitals was obtained from WSHA records. Completion Rates The completion rates for individual questions in the questionnaire varied considerably. Employment statistics for staff nurses were provided by most respondents (e.g., 99% provided counts, 96% provided numbers of vacant FTEs). The response rates for many questions about nurse managers, clinical nurse specialists, and certified nurse practitioners were too low to be analyzed. Questions about the difficulty of nurse recruitment, turnover rates, and salary were completed by most respondents. However, information about the average number of weeks required to fill positions was seldom provided by respondents. Anecdotal information indicates that missing items were often a function of the respondents not being able to obtain the information. The results presented below are from analyses of the survey questions with high completion rates.

14 Results Description of Respondents The survey yielded a response from 68, or 81.9 percent, of the non-federal acute care hospitals in Washington. Respondents included 79.6 percent of the rural hospitals (35 of 44) and 84.6 percent of the urban hospitals (33 of 39). Table 1 shows characteristics of the responding hospitals by size. TABLE 1 Characteristics of Washington Hospitals by Hospital Size Smallest (< 50 beds) Small (50-99 beds) Medium ( beds) Surveyed hospitals Large (> 250 beds) Responding hospitals 31 (88.6%) 9 (69.2%) 15 (83.3%) 13 (76.5%) Average daily acute care occupancy Average number of licensed long term care beds Average number of permanent full-time staff* Average number of part-time staff* Location: Rural Urban (83.9%) 4 (12.9%) 5 (55.6%) 4 (44.4%) 3 (20.0%) 12 (80.0%) 0 (0%) 13 (100%) * Facility-wide.

15 Nurse Demographics Age: More than half (68.6%) of the RN workforce in Washington s acute care hospitals is over the age of 40, and 13.1 percent are age 55 or older (see Figure 4). Nationally, the proportion of all RNs age 40 and over is 68.3 percent (HRSA, 2001). Slightly more of Washington s rural hospital RN workforce is over age 40 compared to urban hospitals (69.7% vs. 67.6%), but urban hospitals employ a greater percentage of RNs age 55 and older (14.3% vs. 11.9%). These rural-urban differences, however, are not statistically significant. FIGURE 4 Age of Washington s Hospital RNs: Average Hospital Percentage by Category 100% 13.1% 14.3% 11.9% 80% 60% 40% 55.5% 53.3% 57.8% Age 55+ Age Age <40 20% 31.4% 32.4% 30.3% 0% All Hospitals (n=64) Urban (n=32) Rural (n=32)

16 Sex: Relatively more male RNs are employed by Washington s hospitals than are among the RN workforce nationally: 8.4 percent in the state s hospitals compared to 5.9 percent in the nation s RN workforce (HRSA, 2001). Rural hospitals employ a higher proportion of male nurses (9.8%) than do urban hospitals in the state (6.9%), although this difference was not statistically significant at the 0.05 level (see Figure 5). FIGURE 5 Gender of Washington Hospital RNs: Average Hospital Percent 100% 80% 60% 40% 91.6% 93.1% 90.2% Female Male 20% 0% 8.4% 6.9% 9.8% All Hospitals (n=66) Urban (n=31) Rural (n=35) Race/Ethnicity: The survey included questions about nurse race and ethnicity, but very few hospitals (19%) were able to respond to these questions.

17 Nurse Employment Rates, Status, and Tenure Employment Rates: Respondents were asked to provide numbers of staff nurses employed, full-time equivalents (FTEs) employed, FTEs budgeted, and FTEs vacant in their acute care facilities. As shown in Figure 6, the responding hospitals reported that they employed 16,186 RN staff nurses. The estimated additional number in non-responding hospitals is 4,500. The estimated total number of staff nurses employed by Washington s acute care hospitals is 20,686. Similarly, the number of FTEs reported by respondents is 10,063, and the imputed number is 4,519, resulting in an estimated total number of FTEs employed by these facilities of 14,582. Urban hospitals employ 86.3 percent of the total count of RNs and 85.8 percent of the total RN FTEs. From the reported numbers, the discount of staff RN counts to FTEs is 70.5 percent. In other words, 100 staff RNs are needed to fill every 70.5 FTE staff RN positions. A recent HRSA report ranked Washington as having the second highest rate in the U.S. of part-time employment among nurses (HRSA, 2000). FIGURE 6 RN Staff Nurses Employed in Washington Hospitals: Counts and FTEs 25,000 20,000 15,000 10,000 5,000 20,686 4,500 16,186 Imputed Reported 14,582 4,519 10,063 - RN Staff Nurses RN Staff Nurse FTEs Non-Permanent Staff: The survey included questions about the total number of staff nursing hours each hospital filled during the past year with on call, per diem, temporary, registry or traveling nurses. Completion rates for these

18 questions were low, and it was not possible to determine if non-respondents did not use these staff or simply did not respond to the question. Because of this uncertainty, imputing values for non-respondents was not feasible. Nonetheless, the 40 percent of hospitals who responded to the questions reported use of 1,082,229 hours of on call and per diem staff, and temporary, registry or traveling nurses. This number is undoubtedly an undercount for the state, but when converted into FTEs, it still represents approximately 550 FTEs, or 3-5 percent of the total reported staff nurse FTEs employed. Tenure: Washington s acute care hospitals report that nearly 45 percent of RN staff nurses have been employed fewer than five years, over 16 percent have been employed five to nine years, and nearly 40 percent have been employed ten years or more (see Figure 7). Urban and rural hospitals reported very similar tenure rates. FIGURE 7 RN Staff Nurse Employment Tenure: Percentage of Nurses Employed in the Same Hospital by Tenure Category 100% 80% 44.9% 42.7% 46.9% 60% 40% 16.3% 15.0% 17.4% % Employed < 5 years % Employed 5-9 years % Employed > 10 years 20% 38.8% 42.3% 35.7% 0% All Hospitals (n=66) Urban (n=31) Rural (n=35)

19 Nurse Salaries Hospitals were asked to report the high end and low end of hourly pay for staff nurses. The averages of the hospitals high and low hourly rates are shown in Figure 8. The average low end of the salary range was similar across hospitals, with less than a dollar difference in average hourly rates between rural and urban facilities. The high end of the range had greater variability: the average for rural hospitals is more than $4.00 lower than the average high hourly salary for urban hospitals. This may be due to the employment of more nurses with specialized training in urban hospitals compared with rural hospitals. In comparison, the actual mean salary of Washington State dental hygienists during the same period was $36.17 statewide, $36.34 for hygienists in urban areas, and $34.48 for hygienists in rural areas (Hart, 2002). FIGURE 8 Staff Nurse Hourly Salary: Average Low and High Rates $35.00 $30.60 $30.00 $27.96 $25.99 $25.00 $20.00 $17.64 $18.37 $17.49 Average Low Average High $15.00 $10.00 $5.00 $-$0 All Hospitals Urban Rural

20 Nurse Vacancy Rates and Turnover Vacancy Rates: As shown in Table 2, the estimated total number of vacant hospital RN staff nurse FTEs in Washington is 1,401. This number is based on the reported total of 1,079 vacant hospital staff nurse FTEs among responding hospitals, with the addition of an imputed 322 vacant FTEs for non-responding hospitals. Because of the high rate of part-time employment among Washington nurses (100 nurses required to fill 70.5 FTEs), an estimated 1,987 nurses are needed to fill the 1,401 vacant FTEs. TABLE 2 RN Staff Nurse Vacancy and Turnover Rates All Hospitals Urban Rural Reported vacant FTEs 1, Total estimated vacant FTEs 1,401 1, Total nurses needed to fill vacancies 1,987 1, Average hospital vacancy rate 9.2% 9.6% 8.9% Overall FTE vacancy rate 10.1% 10.4% 7.4% Turnover rate 16.6% 16.6% 16.6% Vacancy rates can be calculated by different methods. For Washington s hospitals, depending on the method used, the statewide staff nurse vacancy rates ranged from 9.2 percent to 10.1 percent. When the calculation is based on the average of each hospital s vacancy rate, the average staff nurse vacancy rate is 9.2 percent (this method gives equal weight to each hospital s rate, regardless of size). When the calculation is based on the sum of all hospitals FTE vacancies divided by the sum of their budgeted FTEs, the RN staff nurse vacancy rate is 10.1 percent. There was considerable variability among the hospital-specific staff nurse vacancy rates reported: from 0 percent to 43 percent. This variability can be seen in Figure 9, which shows the distribution of individual hospital vacancy rates among the 12 workforce development regions in the state.

21 FIGURE 9 Variability of Hospital RN Staff Nurse Vacancy Rates by Washington State Workforce Development Region 45% FTE Vacancy Rate 40% 35% 30% 25% 20% 15% 10% 5% Urban hospitals Rural hospitals 0% Washington Workforce Development Regions* * 1 = Olympic 5 = Seattle-King 9 = Tri-County 2 = Pacific Mountain 6 = Tacoma-Pierce 10 = Eastern Washington Partnership 3 = Northwest 7 = Southwest 11 = Benton-Franklin 4 = Snohomish 8 = North Central 12 = Spokane On average, rural hospitals report lower staff nurse vacancy rates than do urban facilities. Washington s urban hospitals report an average vacancy rate (average hospital-specific rate) of 9.6 percent, while rural hospitals report 8.9 percent. The American Hospital Association reports national nurse vacancy rates of 12 percent for urban and 10 percent for rural hospitals in 2001 (AHA, 2001). Washington appears to be in the low-average range for hospital nurse vacancy rates among the states; California 20 percent for 2000, Maryland 14.7 percent for 2000, Florida 16 percent for 2001, Nevada 13 percent for 2001, and Vermont 7.8 percent for 2001 (GAO, 2001). Caution should be used in

22 comparing Washington with other states because, as described earlier, the methods for calculating the vacancy rates may vary. Turnover: Overall RN staff nurse turnover rates (total number of nurses leaving/total average number employed during the past year) are identical in rural and urban Washington hospitals: 16.6 percent. However, nearly 54 percent of urban hospitals but only 14.3 percent of rural hospitals reported that their turnover increased during the past year (see Figure 10). FIGURE 10 RN Staff Nurse Turnover Rates: This Year Compared with Last Year 100% 11.5% 19.3% 5.7% 80% 60% 40% 20% 0% 26.9% 57.4% 80.0% 53.8% 31.1% 14.3% All Hospitals Urban Rural Lower About the same Higher

23 Patient Diversion: When asked whether a shortage of nurses caused the hospitals to divert patients to other facilities during the past year, 55.2 percent of the hospitals reported they had. More urban hospitals than rural hospitals reported diverting patients because of a shortage of nurses (65.6% versus 45.7% see Figure 11). Almost a quarter of all hospitals indicated a shortage of nurses caused them to divert patients for 10 days or more during the past year, and among urban hospitals nearly half (43.8%) diverted patients 10 or more days. Isolated rural hospitals may not be able to divert as readily as other hospitals because of the lack of timely alternative destinations for their potential patients. FIGURE 11 Hospital Use of Divert Status Because of Nursing Shortage During Past Year 55.2% Went on Divert Used Divert >10 Days 23.9% 45.7% 43.8% 65.6% Statewide Urban Rural 5.7% 0.0% 20.0% 40.0% 60.0% 80.0% Nurse Recruitment and Retention Newly Trained vs. Experienced Nurses: Urban hospitals in Washington report having a somewhat easier time recruiting newly-trained RNs than do rural hospitals: 12.1 percent of urban hospitals reported hiring newly-trained nurses was very difficult compared with 37.9 percent of rural hospitals. However, when asked about recruiting experienced nurses, the majority of both

24 urban and rural hospitals reported recruitment is very difficult (66.7% and 62.5%, respectively). Nearly all hospitals (97%) report that it is somewhat or very difficult to hire experienced nurses (see Figures 12 and 13). FIGURE 12 Difficulty Recruiting Newly-Trained RNs 100% 80% 25.8% 27.3% 24.2% 60% 40% 50.0% 60.6% 37.9% Not difficult Somewhat difficult Very difficult 20% 0% 37.9% 24.2% 12.1% All Hospitals Urban Rural FIGURE 13 Difficulty Recruiting Experienced RNs 100% 3.1% 0.0% 6.2% 80% 32.3% 33.3% 31.3% 60% 40% 20% 64.6% 66.7% 62.5% Not difficult Somewhat difficult Very difficult 0% All Hospitals Urban Rural

25 When questioned about whether nurse recruitment is more difficult than one year ago, 37.9 percent of hospitals reported hiring newly trained nurses was more difficult, and 58.1 percent reported experienced nurses were more difficult to recruit. Again, urban hospitals reported more change in recruitment difficulty than rural hospitals (see Figures 14 and 15). FIGURE 14 Difficulty Recruiting Newly Trained RNs: This Year Compared with Last Year 100% 0.0% 0.0% 0.0% 80% 60% 40% 62.1% 55.2% 69.0% Less Difficult About the Same More Difficult 20% 37.9% 44.8% 31.0% 0% All Hospitals (n=62) Urban (n=33) Rural (n=29) FIGURE 15 Difficulty Recruiting Experienced RNs: This Year Compared with Last Year 100% 0.0% 0.0% 0.0% 80% 60% 40% 20% 41.9% 58.1% 31.0% 69.0% 51.5% 48.5% Less Difficult About the Same More Difficult 0% All Hospitals (n=65) Urban (n=33) Rural (n=32)

26 Nurse Specialties: Some nurse specialties are more difficult to recruit than others. Table 3 orders nurse specialty by the percentage of hospitals who indicated the specialty was very difficult to recruit. ICU/CCU, anesthesia, emergency, and operating room (OR)/recovery specialties top the list. This is probably because more experience is required of nurses filling positions in these specialties than, for example, a medical/surgical unit position, where newly trained nurses are often placed. Urban and rural hospitals listed similar specialties as most difficult to recruit now compared to one year ago. Because many rural hospitals do not employ as many different specialties as do urban hospitals, it is difficult to compare the rankings in detail. TABLE 3 Comparative Difficulty of Recruiting RNs by Specialty Hospitals Reporting Recruitment as Very Difficult * Nurse Specialty Percent Number ICU/CCU 83.3% 40 Anesthesia 76.5% 13 Emergency 65.5% 36 OR/recovery 62.3% 33 Labor and delivery 56.0% 28 Oncology 50.0% 14 Medical/surgical 33.9% 20 Pediatrics 33.3% 8 Neonatology 31.6% 6 Psychiatry 25.0% 4 Rehabilitation 17.6% 3 * Of hospitals that employ the specialty.

27 Reasons for Shortages: Hospitals were asked to identify the primary reason they felt they had nurse vacancies. A majority of hospitals (59.3%) said there were not enough applicants, and another 20 percent indicated there were too few applicants qualified for the available positions (see Table 4). Very few hospitals cited pay or benefits as a primary reason for nurse vacancies only five percent (or three hospitals) cited not being able to pay competitively, three percent (two hospitals) said their benefits were not good enough, and another three percent (two hospitals) reported the main reason for their nurse shortage was that they were hampered by pay scale restrictions (e.g., union contract specifications of allowable salary ranges for new hires). TABLE 4 Principal Reason for RN Vacancies Reason % of Hospitals Citing as Principal Reason* Not enough applicants 59.3% Lack of qualified applicants 20.4% Not able to pay competitively 5.0% Benefits not good enough 3.4% Pay scale restrictions 3.1% Other 8.9% * Respondents who inappropriately selected more than one reason had their responses weighted. Strategies to Improve Recruitment and Retention Hospitals were asked about a variety of methods to improve nurse recruitment and retention.

28 Nursing Education: Participation in training with a local nursing school was one method of recruiting and retaining nurses that was investigated. Of the nearly 78 percent of hospitals who indicated that they participate in nurse training with a local nursing school, fewer rural hospitals (68.6%) reported this educational pairing than did urban hospitals (87.9%) (see Table 5). One quarter of hospitals statewide reported participating in distance education programs for nurses. Rural hospitals (30.3%) were more likely to participate than urban hospitals (18.8%). TABLE 5 Hospital Participation in RN Education All Hospitals Urban Rural Participate in nurse training with local nursing school Participate in distance education programs for nurses* 77.9% 87.9% 68.6% 24.6% 18.8% 30.3% * For training or continuing nurse education. Out-of-State Recruitment: The hospitals do not limit their recruitment activities to Washington State. As shown in Table 6, 69.1 percent recruit from other states, and 26.5 percent recruit from other countries. Idaho and Oregon were the states named most often, but many hospitals reported that they regularly recruit nationwide. Canada was cited most often as a recruitment target outside the U.S., but four hospitals reported they recruited from the Philippines, and other hospitals named specific countries, including Mexico, Australia, New Zealand, and the United Kingdom. Rural hospitals were much less likely than urban hospitals to recruit nurses from outside the U.S. and somewhat less likely to recruit from other states. TABLE 6 Nurse Recruitment Outside Washington State All Hospitals Urban Rural From other states 69.1% 78.8% 60.0% From other countries 26.5% 36.4% 17.1%

29 Incentives: Washington s acute care hospitals use many incentives to enhance nurse recruitment and retention. Seventy percent or more use supplemental pay (for off shift, specialty care, weekend or on-call work), tuition reimbursement and/or on-site continuing nurse education (CNE) as incentives (see Figure 16). Fewer than 20 percent of the hospitals reported using higher pay or enhanced career ladders as recruitment and retention incentives. FIGURE 16 Percentage* of Hospitals Using RN Recruitment and Retention Incentives Supplemental Pay** Tuition Reimbursement On-Site CNE 70.1% 78.8% 76.1% Flexible Hours 58.2% Good Benefit Packages Convenient/Low Cost Parking Promotions/Salary Increases Shared Governance Sign-On Bonuses Scholarships Career Ladder Opportunities Higher Salaries Higher Overtime Pay On-Site Child Care 44.8% 41.8% 37.3% 33.8% 32.8% 27.3% 18.2% 16.7% 15.2% 12.1% * Of 68 total hospital respondents. The 95% confidence interval for each measure, from top to bottom is ± 19.8%, ± 20.4%, ± 22.0%, ± 23.6%, ± 23.8%, ± 23.6%, ± 23.2%, ± 22.4%, ± 22.4%, ± 21.4%, ± 18.6%, ± 18.0%, ± 17.4%, ± 15.8%. ** For off shift, specialty care, weekend and on-call work.

30 When asked which incentives the respondents felt were effective for recruiting and retaining nurses, no consensus emerged. With regard to recruitment, no single incentive was cited by more than 24 percent of the hospitals (see Figure 17). Sign-on bonuses and good benefit packages were the most-often cited, but these methods were still only referred to by 23.5 percent of the hospitals. Nearly 18 percent of the hospitals said none of these incentives were effective in recruiting nurses. FIGURE 17 Percentage* of Hospitals that Identify Incentive as Effective for RN Recruitment Good Benefit Packages Sign-On Bonuses Tuition Reimbursement Supplemental Pay** Shared Governance Promotions/Salary Increases On-Site CNE Career Ladder Opportunities Convenient/Low Cost Parking Scholarships On-Site Child Care Flexible Hours Higher Salaries Higher Overtime Pay None of the Above 23.5% 23.5% 17.6% 11.8% 8.8% 5.9% 4.4% 4.4% 2.9% 2.9% 1.5% 0.0% 0.0% 0.0% 17.9% * Of 68 total hospital respondents ** For off shift, specialty care, weekend and on-call work. For nurse retention, 27.9 percent of hospital respondents said good benefit packages were useful (see Figure 18). No other retention method was cited as

31 effective by more than 18 percent of the hospitals. According to 10.3 percent of respondents, none of the listed methods were effective in retaining nurses. FIGURE 18 Percentage* of Hospitals that Identify Incentive as Effective for RN Retention Good Benefit Packages Tuition Reimbursement Supplemental Pay** Shared Governance Promotions/Salary Increases On-Site CNE Convenient/Low Cost Parking Career Ladder Opportunities Higher Overtime Pay On-Site Child Care Sign-On Bonuses Scholarships Flexible Hours Higher Salaries None of the Above 27.9% 17.6% 11.8% 10.3% 8.8% 7.4% 7.4% 7.4% 4.4% 2.9% 1.5% 1.5% 0.0% 0.0% 10.3% * Of 68 total hospital respondents. ** For off shift, specialty care, weekend and on-call work. Several other incentives, not among the list provided in the questionnaire, were added by respondents and cited as being effective in recruiting and retaining nurses. Those most frequently added methods for recruiting and retaining nurses can be categorized as: (1) promoting teamwork and having a positive working environment (mentioned by 10.3% of hospitals), (2) providing relocation bonuses and incentives (8.8%), and (3) being located in a desirable location (5.9%). Other incentives mentioned include having low patient-nurse ratios, having residency training programs, and providing referral bonuses.

32 Rural hospitals were not meaningfully different from urban hospitals with regard to questions about nurse recruitment and retention strategies. Why Do Some Hospitals Have Less of a Nurse Shortage Problem? While the majority of Washington s acute care hospitals are suffering a shortage of nurses, the problem is not universal. Some hospitals report low nurse vacancy rates (including eight who report they have no vacancies) and report that recruiting nurses is not difficult. The data from the survey were used to attempt to identify any systematic explanation for differences between the hospitals with clear nurse shortages, and those affected less by the problem. To see if there was an effective difference in recruiting and retention strategies among hospitals, the extent to which the hospitals used recruitment/retention methods was compared. Hospitals reporting it was very difficult to recruit experienced nurses (42 in total) were compared to those that reported it was somewhat (21 total) or not difficult (2 total) to recruit experienced nurses. Figure 19 shows how the two groups compare by use of these methods. The top four incentives on the list for both groups are identical to the rank of incentives shown in Figure 16. Supplemental pay, followed by tuition reimbursement, onsite CNE and flexible hours are being used by the majority of hospitals, whether or not they are having trouble recruiting experienced nurses. More of the hospitals that have less difficulty with recruitment report using higher salaries as an incentive (28.6% versus 11.9%), but this difference was not statistically significant. However, the vast majority of both groups do not report that they use higher salaries as an incentive. Fewer of the hospitals that had less difficulty recruiting nurses use sign-on bonuses than do the hospitals for whom recruitment is very difficult.

33 FIGURE 19 Percentage* of Hospitals Using Nurse Recruitment and Retention Incentives: Comparison of Hospitals where Recruitment Is Very Difficult vs. Somewhat or Not Difficult Supplemental Pay** Tuition Reimbursement On-Site CNE Flexible Hours Good Benefit Packages Convenient/Low Cost Parking Promotions/Salary Increases Shared Governance Sign-On Bonuses Scholarships Career Ladder Opportunities Higher Salaries Higher Overtime Pay On-Site Child Care 75.6% 81.8% 73.8% 81.8% 69.0% 77.3% 59.5% 59.1% 42.9% 50.0% 35.7% 50.0% 35.7% 45.5% 31.0% 39.1% 38.1% 22.7% 31.7% 18.2% 22.0% 13.6% Recruitment 11.9% "Very Difficult" 28.6% 19.5% Recruitment 9.1% "Somewhat" or 19.5% "Not Difficult" 0.0% * Of 42 hospitals where recruiting experienced nurses was very difficult and of 22 hospitals where recruiting experienced nurses was somewhat or not difficult. ** For off-shift, specialty care, weekend, and on-call work.

34 There was little difference between the two groups of hospitals and their participation with local nursing schools, and the extent to which they provide distance education opportunities (see Table 7). TABLE 7 Participation in RN Education, by Level of Difficulty Recruiting Experienced Nurses Participate in Nurse Training with Local Nursing School Participate in Distance Education Programs for Nurses* More Difficult* Less Difficult** 76.2% 82.6% 22.5% 27.3% * Hospital reported that recruiting experienced nurses is very difficult (n = 42). ** Hospital reported that recruiting experienced nurses is somewhat or not difficult (n = 22). Discussion Similar to hospitals across the country, Washington s acute care hospitals are dealing with the challenge of a nursing shortage. The results of this hospital survey help us to understand the extent to which hospitals are affected and suggest trends for the future. There are several limitations to the extent that this study s findings can be used to make conclusions about the state s hospital nurse workforce. First, the study is limited by being a cross-sectional, or onepoint-in-time, measure, and trends cannot be concluded from these results alone. The survey s response rate was high (82%), but because 15 of the 83 acute-care hospitals in Washington did not respond, the findings remain estimates of statewide measures. Many of the questions yield perceptions (i.e., qualitative responses to questions such as How difficult is recruitment? ) rather than more objective quantitative measures (i.e., How many FTEs are vacant? ). These qualitative responses are subjective, and responses may vary somewhat among respondents in the same hospital. For this reason, only large differences in qualitative responses among hospitals were considered meaningful in these analyses. Another limitation of this study is that it elicited insights about the nursing shortage from employers (hospitals) and not from nurses. A logical complement to this study would be to survey the nurse workforce to learn more about their reasons for choosing different work sites or leaving the profession.

35 One conclusion that can be made from this study is that nearly 2,000 RNs are estimated to be needed now to fill hospital vacancies alone, not to mention needs in other nurse employment settings. The WSHA reports that Washington s nursing schools graduate approximately 1,200 registered nurses each year. In the short term, the nursing schools in Washington cannot be counted on to train new nurses in adequate numbers to meet the state s needs. The majority of RN staff nurses in the state s hospitals are over the age of 40, and if the national aging trend of nurses continues in Washington, retirement will further erode the nurse supply in this state. While this study alone cannot predict long-term trends in nurse supply in Washington, there is clearly a shortage now in the state s hospitals, and the demand for nurses is increasing with the growth and aging of Washington s population. There should be concern about the extent to which supply can meet demand in the future. One short-term result of the nursing shortage in Washington s hospitals is the closing of hospital beds. Two-thirds of the state s hospitals diverted patients to other hospitals because of nurse shortages: 44 percent of the state s urban hospitals had to divert patients more than ten days in the year prior to the survey (rural hospitals diverted patients less frequently, but that may be because their remoteness provides fewer options for diversion). Diverting patients is not in the best interest of patients and represents loss of business for hospitals. Other short-term effects of the RN shortage are that more management and supervisory resources must be spent in nurse recruitment efforts and orientation of new and temporary staff than if the hospital had fewer vacancies and less turnover. A sizeable portion of the nursing provided in Washington s hospitals is by on call, per diem, temporary, registry, and traveling nurses, many of whom are filling vacancies in permanent positions. This means more of managers and supervisors time is taken away from supervision, mentoring and support of already-employed staff nurses, and likely increases the stress in the nurses work environment. The nurse shortage is also one of the reasons many hospital nurses are working many overtime hours. The long-term effects of the nurse shortage cannot be measured by this study, but difficult working environments and long working hours increase the chances that nurses will be dissatisfied with their work, undermine retention efforts, and increase risks to the quality of patient care. Not all of Washington s hospitals are experiencing nursing shortages to the same degree or in the same way. The nurse shortage is being felt in both rural and urban hospitals, but urban hospitals have somewhat higher vacancy rates.

36 Experienced and specialty RNs are difficult to recruit for both rural and urban hospitals, but rural hospitals report having a more difficult time recruiting newly trained nurses than do urban hospitals. Urban hospitals are more likely than rural hospitals to be in proximity to a nursing school, and therefore are more likely to team up with schools for nurse training. Efforts to create more clinical training opportunities for nurses in rural hospitals could help alleviate those hospitals recruitment problems. The state s hospitals are using a large variety of methods to improve their ability to recruit and retain nursing staff. However, none appears to be a magic bullet solution, given the limited supply of nurses in the state. Washington s hospitals see shortage of nurse supply as the main reason for their shortage, not inability to compete with other employers on pay or benefits. A survey of the state s nurses would help paint a more complete picture of what works best to recruit and retain nurses in the hospital workforce. To alleviate the current nurse shortage in Washington, an increase in the nurse supply must come from one or more of four sources: increased production from the state s nursing schools, increased importation of nurses from outside Washington, reduction of retirement rates, and reduced attrition from the profession. Importing nurses only exacerbates nurse shortages in other states or countries and should only be considered as a short-term method to deal with the problem. Washington will likely experience the greatest success by (1) supporting initiatives that focus on improving the quality of nurses working conditions in order to improve recruiting ability and reduce attrition and (2) encouraging the training of more nurses in the state. Washington State currently has one of the highest unemployment rates in the U.S. Applicants for additional nurse training slots in the state s nursing schools could be filled from among the state s recently unemployed, as well as from outreach efforts to men and racial/ethnic minorities groups underrepresented to-date in the nursing workforce. Washington s employers, policy makers, nurses, and potential nurses stand to benefit from increased national and state attention to the nursing workforce problem. Innovative and timely use of training and workforce development resources may help solve the current nurse shortage, and a long-term strategy to monitor the nurse workforce, including longitudinal research, will help prevent this problem in the future.

37 References American Hospital Association (AHA) (2001). AHA TrendWatch, vol. 3, no. 2. Buerhaus PI, Staiger DO, Auerbach DI (2000). Implications of an aging registered nurse workforce. JAMA, 283(22): Center for Health Workforce Studies (2001). The Health Care Workforce in New York City, 2001: Trends in the Supply and Demand for Health Workers in New York City. Rensselaer, NY: The Center for Health Workforce Studies, School of Public Health, University at Albany. First Consulting Group for the American Hospital Association (2001). The Healthcare Workforce Shortage and Its Implications for America s Hospitals. Available at: FcgWorkforceReport.pdf. Accessed March 6, Furino A, Gott SP, Miller DR (2000). Health and Nurses in Texas. The Future of Nursing: Data for Action. San Antonio, TX: The Nurse Workforce Data System at CHEP. General Accounting Office (GAO) (2001). Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. Washington, DC: U.S. General Accounting Office. Hart LG (2002) Washington State Dental Association Survey of Dentists. Report to the Washington State Dental Association. Hospital and Healthcare Compensation Service (2000). Hospital Salary and Benefits Report, Oakland, NJ: Author. Morrill R, Cromartie J, Hart LG (1999). Metropolitan, urban, and rural commuting areas: toward a better depiction of the U.S. settlement system. Urban Geography, 20(8): North Carolina Center for Nursing (2001). Nursing Shortage Areas in North Carolina Hospitals. Raleigh, NC: Author.

38 Sechrist KR, Lewis EM, Rutledge DN (1999). The California Nursing Work Force Initiative. Planning for California s Nursing Work Force: Phase II Final Report. Irvine, CA: California Strategic Planning Committee for Nursing, Colleagues in Caring: Regional Collaboratives for Nursing Work Force Development. U.S. Health Resources and Services Administration (2000). HRSA State Health Workforce Profiles: Washington. Rockville, MD: Bureau of Health Professions, National Center for Health Workforce Information and Analysis, HRSA, U.S. Department of Health and Human Services. U.S. Health Resources and Services Administration (2001). The Registered Nurse Population: National Sample Survey of Registered Nurses March Preliminary Findings. Rockville, MD: Division of Nursing, Bureau of Health Professions, HRSA, U.S. Department of Health and Human Services. Urban Institute (2001). The Long-Term Care Financing Model. Prepared by The Lewin Group, Inc., for the Office of the Assistant Secretary for Planning and Evaluation, DHHS, 2000.

39 APPENDIX: Questionnaire

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41 Hospital Workforce Survey: Nursing and Allied Health Instructions Please answer the following questions to the best of your ability. It may help to first review the definitions and instructions at the start of each section. There is also a glossary of job titles at the end of the questionnaire that may be useful. A. Hospital Characteristics The questions in this section will help us understand the size and complexity of your hospital facility. How many licensed acute-care beds does your hospital have? acute care beds What was your hospital s average daily occupancy (acute care) last year? patients In addition to your acute care beds, how many licensed long term care beds does your hospital have? long term care beds On average, how many total permanent full-time staff (all professions in all units) does your hospital employ? full-time employees On average, how many total permanent part-time staff (all professions in all units) does your hospital employ? part-time employees What is your hospital s fiscal year? January-December July-June Other (specify): B. Nursing This section s questions are about the nursing staff who support your acute care hospital. If your hospital also supports non-acute care functions (long-term care, outpatient, etc.), please answer the following questions only as they relate to support of your hospital s acute care functions. Job Titles: Not all job titles listed in this questionnaire will match with those used at your institution. Please use your best judgement in matching your job titles with the job descriptions listed in the glossary at the end of this questionnaire. RN: RN refers to a registered nurse providing direct patient care utilizing the nursing process which includes assessment, nursing diagnosis, planning, implementation, and evaluation of care. Responsibilities may also include: patient teaching and counseling, administering treatments and medications, documenting care given and patients response to treatment, and supervising. Full Time Equivalent Position (FTE): Total number of hours per year considered an FTE varies by institution and contract the range is usually between 1860 and 2080 hours per year (30-40 hours per week). One FTE is indicated 1.0 FTE. Indicate part-time positions as follows: a halftime position = 0.5 FTE; a quarter-time position = 0.25 FTE. Example: A facility has four RN positions. Two of the positions are for full-time staff nurses and the third is for a half-time staff nurse. The fourth position works half time as a staff nurse and half time as a supervisor. This facility has 3.0 staff nurse FTEs and 0.5 administrative/supervisor/manager. Page 1 of 10 mar SONS:z:q:s 3/2/01